La. Admin. Code tit. 40 § I-5313

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5313 - Billing Instructions

A. The American Dental Association (ADA) claim form is to be used for billing services provided to workers' compensation employer claimants. Do not use any other form.

B. Partial bills should not be filed by the provider or the claimant. An invoice for the full amount must be filed by one of the two parties. If the claimant pays for medical or other services which are determined to be compensable expenses, it is his responsibility to file the ADA dental claim form, with the workers' compensation carrier/self-insured employer to receive reimbursement.

C. This is not the case if the provider agrees to file for the claimant; the carrier will pay directly to the provider and the provider must refund any partial payments made by the claimant directly to the claimant.

D. Please read the instructions carefully before completing the form. Failure to provide the information requested in a readable form will result in delay of payment.

E. A sample ADA dental claim form and detailed instructions for the proper completion of the form follows.

Sample ADA Form

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F. Item-by-Item Instructions for Completion of the ADA Dental Claim Form. This Section is intended to serve as an instructional guide for completing the ADA dental insurance claim form. All applicable information should be completed in full.

Dentist's Pretreatment Estimate, or Statement of Actual Services : Check the appropriate box to indicate if the form is being used for an estimate and authorization, or if the form represents a statement of actual services.
Carrier Name and Address : Enter the name and address of the carrier where the claim is to be sent.
Item 1	Patient's Name -enter the patient's first name, middle initial and last name.
Item 2	Relationship to Employee -"Self" is the claimant. (Workers' compensation claims should always show "self".) Put an "X" in the appropriate box.
Item 3	Sex -put an "X" in the appropriate box; male or female.
Item 4	Patient Birthdate -enter the patient's date of birth, month, day and year.
Item 5	If Full-Time Student -leave blank.
Item 6	Employee/Subscriber Name and Address -same as patient's name and address.
Item 7	Employee/Subscriber Social Security or I.D. Number -if the patient has other insurance, show the insured's policy number.
Item 8	Employee/Subscriber Birthday -same as patient's birthday.
Item 9	Employer (Company name and address) -enter the employer's (company's) name and address.
Item 10	Group Number -if the patient has other insurance, show the insured's group number.
Item 11	Is Patient Covered By Another Dental Plan? Leave blank.
Item 12a	Name and Address of Carrier -Leave blank.
Item 12b	Group Number -Leave blank.
Item 13	Name and Address of Other Employer(s) Leave blank.
Item 14a	Employee/Subscriber Name (If Different Than Patient's) Leave blank.
Item 14b	Employee/Subscriber Social Security Or I.D. Number -Leave blank.
Item 14c	Employee/Subscriber Birth Date -Leave blank.
Item 15	Relationship to Patient -Leave blank.
Patient Signature -Have the patient or his authorized representative sign and date this block unless the signature is on file. If the patient's representative signs, the relationship to the patient must be indicated. The patient's signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the physician or supplier.
Signature by Mark -Where an illiterate or physically handicapped person signs by mark (X), a witness must enter his/her name and address next to the mark.
Insured Person's Signature Block -The signature in this block authorizes payment to the physician or supplier.
Item 16	Name of Billing Dentist or Entity -Enter the individual dentist's name or the name of the group/practice corporation responsible for the billing. This may differ from the actual treating dentist's name. This is the name that should appear on any payments or correspondence that will be remitted to the billing dentist.
Item 17	Address Where Payment Should Be Remitted -Enter the address of the billing dentist or entity in Item 16.
Item 18	Dentist's Social Security Number or T.I.N. -Show your physician/supplier federal tax I.D. (Employer Identification Number) or Social Security number.
Item 19	Dentist's License Number -Enter the license number of the billing dentist. This may differ from that of the treating dentist, which appears in the dentist's signature block at the bottom of the form.
Item 20	Dentist's Phone Number -Enter the dentist's area code and phone number.
Item 21	First Visit Date Current Series -Enter the date of the first visit in the current series of treatment.
Item 22	Place of Treatment -Enter the appropriate place of service code from the list provided.
Place of Service Codes and Definitions
Codes	Definitions
00-10	Unassigned
11	Office -Location, other than a hospital, skilled nursing facility (SNF), military treatment facility. Community health facility, state or local public health clinics or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory basis.
12	Patient's Home -Location, other than a hospital or other facility, where the patient receives care in a private residence.
13-20	Unassigned
21	Inpatient Hospital -A facility, other than psychiatric, which primarily provides diagnostic therapeutic (both surgical and nonsurgical) and rehabilitation services, or under the supervision of physicians to patients admitted for a variety of medical conditions.
22	Outpatient Hospital -A portion of a hospital which provides diagnostic, therapeutic (both surgical or nonsurgical) and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23	Emergency Room-Hospital -A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
24	Ambulatory Surgical Center -A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.
25	Birthing Center -A facility, other than a hospital's maternity facility or a physician's office, which provides a setting for labor, delivery and immediate post-partum care as well as immediate care of newborn infants.
26	Military Treatment Facility -A medical facility operated by one or more of the uniformed services. Military treatment facility (MTF) also refers to certain former U.S. Public Health Services (USPHS) facilities now designated as uniformed service treatment facilities (USTF).
27-30	Unassigned
31	Skilled Nursing Facility -A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services but does not provide the level of care or treatment available in a hospital.
32	Nursing Facility -A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled or sick persons, or, on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals.
33	Custodial Care Facility -A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
34	Hospice -A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.
35-40	Unassigned
41	Ambulance-Land -A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
42	Ambulance-Air or Water -An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
43-50	Unassigned
51	Inpatient Psychiatric Facility -A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52	Psychiatric Facility Partial Hospitalization -A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full-time hospitalization, but who need broader programs than are possible from outpatient visits in a hospital-based or hospital-affiliated facility.
53	Community Mental Health Center -A facility that provides comprehensive mental health services on an ambulatory basis primarily to individuals residing or employed in a defined area.
54	Intermediate Care Facility/Mentally Retarded -A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.
55	Residential Substance Abuse Treatment Facility -A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56	Psychiatric Residential Treatment Center
57-60	Unassigned
61	Comprehensive Inpatient Rehabilitation Facility -A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
62	Comprehensive Outpatient Rehabilitation Facility -A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
63-64	Unassigned
65	End Stage Renal Disease Treatment Facility -A facility other than a hospital, which provides dialysis treatment, maintenance and/or training to patients or care givers on an ambulatory or home-care basis.
66-70	Unassigned
71	State or Local Public Health Clinic -A facility maintained by either state or local health departments that provides ambulatory primary medical care under the general direction of a physician.
72	Rural Health Clinic -A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
73-80	Unassigned
81	Independent Laboratory -A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.
82-98	Unassigned
99	Other Unlisted Facility -Other service facilities not identified above.
Item 23	Radiographs or Models Enclosed -Indicate whether diagnostic materials were submitted.
Item 24	Is Treatment Result of Occupational Illness or Injury? Check yes or no to indicate whether employment related.
Item 25	Is Treatment Result of Auto Accident? Check yes or no to indicate whether injury is related to auto accident.
Item 26	Other Accident -Check yes or no to indicate accident other than employment or auto related.
Item 27	If Prosthesis, Is This The Initial Placement? -Check yes or no.
Item 28	Date of Prior Placement? Enter the date of prior placement if applicable.
Item 29	Is Treatment for Orthodontics? Check appropriate box.
Item 30	Examination and Treatment Plan -Enter the examination and/or plan of treatment. List in order from Tooth #1 through Tooth #32 using the charting system shown.
Item 31	Remarks for Unusual Services -Enter any information which may be helpful in determining the most appropriate benefit for the treatment. If space is inadequate, utilize unused portion of #30, or attach a separate sheet.
Dentist's Signature Block -Must include treating dentist's signature and license number.
Payment Itemization -The spaces under "Total Fee Charged" will be completed by the carrier.

La. Admin. Code tit. 40, § I-5313

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:1163 (September 1993), amended LR 20:1298 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.